Provider Demographics
NPI:1316960842
Name:WILLIS, BYRON H (MD)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:H
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1331 N 7TH ST STE 405
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2754
Mailing Address - Country:US
Mailing Address - Phone:602-254-3151
Mailing Address - Fax:602-256-9581
Practice Address - Street 1:1331 N 7TH ST STE 405
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2754
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ30100207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0712750OtherBCBS
AZ686058Medicaid
AZ188316200OtherDEPT. OF LABOR
AZ1Z4006OtherHEALTHNET
AZAZ0712750OtherBCBS
AZ686058Medicaid